I hereby consent to engaging in telehealth as it relates to the treatment and care of my wound healing progress.

I understand that “telehealth” provided by the Certified Wound Specialists at Divine Healthcare Consultants LLC include consultations, treatment recommendations, transfer of medical data, and education using interactive audio, video, or data communications.

I understand that I have the following rights with respect to telehealth: (1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. (2) The laws that protect the confidentiality of my medical information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my treatment is generally confidential.

However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.

I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to researchers or other entities shall not occur without my written consent. (3) I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of my Certified Wound Specialist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

In addition, I understand that telehealth based services and care may not be as complete as face-to-face services. I also understand that if my Certified Wound Specialist believes I would be better served by direct (i.e. face-to-face) interaction and if I am unable to meet with my referring physician or primary care physician face-to-face I will be referred to a professional who can provide such services in my area.

Finally, I understand that there are potential risks and benefits associated with any form of wound care, and that despite my efforts and the efforts of my Certified Wound Specialist, my wound may not improve, and in some cases may even get worse. (4) I understand that I may benefit from telehealth, but the results cannot be guaranteed or assured. (5) I understand that I have a right to access my medical information and copies of medical records in accordance with (Insert State) law.

I have read and understand the information provided above. I understand that any questions that I may have, I can discuss it with my Certified Wound Specialist, and all of my questions have been answered to my satisfaction.

I understand that my treatment or continued treatment by Divine Healthcare Consultants LLC is in no way conditioned on whether or not I sign this authorization and that I may refuse to sign it. I understand that under applicable law the information disclosed under this authorization may be subject to further disclosure by the recipient and thus, may no longer be protected by federal privacy regulations. I understand that I may inspect or request a copy of the information to be used or disclosed by the recipient. This authorization will be valid for a period of one year from the signature date below. Medical records will only be released for dates of service which occur prior to the authorization date unless disclosure of a future service date is specifically authorized. I understand that I may cancel this authorization at any time by notifying Divine Healthcare Consultants LLC in writing, but if I do it will not have any effect on actions that the release took before it received the cancellation. Copy Fees: I understand that Divine Healthcare Consultants LLC may charge a fee for copying and first class postage to the individual receiving the requested information. Copy fees will be applied in accordance with the state of Texas Statute at $25 for 500 pages or less and $50 for more than 500 pages.